Star Cancellation Test

Purpose

The Star Cancellation Test is a screeningTesting for disease in people without symptoms.
tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

In-Depth Review

Purpose of the measure

The Star Cancellation Test is a screeningTesting for disease in people without symptoms.
tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Available versions

The Star Cancellation Test was developed by Wilson, Cockburn, and Halligan in 1987.

Features of the measure

Items:
There are no actual items to the Star Cancellation Test. In the Star Cancellation Test, the stimuli are 52 large stars, 13 letters, and 10 short words interspersed with 56 smaller stars (see figure below). The patient must cross out with a pencil all the small stars on an 8.5″ x 11″ piece of paper. Two small stars in the centre are used for demonstration. The page is placed at the patient’s midline.

Scoring:
The maximum score that can be achieved on the test is 54 points (56 small stars in total minus the 2 used for demonstration). A cutoff of < 44 indicates the presence of USN. A Laterality Index or Star Ratio can be calculated from the ratio of stars cancelled on the left of the page to the total number of stars cancelled. Scores between 0 and 0.46 indicate USN in the left hemispace. Scores between 0.54 and 1 indicate USN in the right hemispace

Time:
Less than 5 minutes.

Training:
None typically reported.

Subscales:
None.

Equipment:

• The test paper (8.5″x11″ page with 52 large stars, 13 letters, and 10 short words interspersed with 56 smaller stars).
• Pencil

Alternative forms of the Star Cancellation Test

Laterally extended version of the Star Cancellation Test (Small, Cowey, & Ellis, 1994). In this version of the test, the section in the traditional version of the Star Cancellation Test extending from the midline to the right side of the page is duplicated at the right end (i.e. the display area is extended twice as far to the right of midline as to the left). The dimensions of the test paper in this version are 41 cm x 21 cm.

Client suitability

Can be used with: Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

• Patients must be able to hold a pencil to complete the test (the presence of apraxia may impair this ability).
• Patients must be able to visually discriminate between distractor items such as the words and big stars, and the small stars that are to be cancelled.

Should not be used with:

• As with other cancellation tests, the Star Cancellation Test cannot be used to differentiate between sensory neglect and motor neglect because it requires both visual search and manual exploration (Ladavas, 1994).
• The Star Cancellation Test cannot be completed by proxy.

In what languages is the measure available?

The words included in the Star Cancellation Test can be translated into the patients’ native language (Linden, Samuellson, Skoog, & Blomstrand, 2005).

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the near extra personal space.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	Laterally extended version of the Star Cancellation Test
Other Languages	The words can be translated into the patients’ native language.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Star Cancellation Test. Test-retest: One study has examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Star Cancellation Test and reported excellent test-retest. Inter-rater: No studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Star Cancellation Test.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Predictive: One study reported that out of 4 different measures of USN (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph), the Star Cancellation Test was the best predictor of functional outcome. Construct: Convergent: The Star Cancellation Test correlated adequately with the Barthel Index, the Line Bisection Test, the Clock Drawing Test, and the Copy A Cross Test. The test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Line Crossing Test and with the Indented Paragraph test.
Does the tool detect change in patients?	Not applicable.
Acceptability	The Star Cancellation Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil and visually discriminate between distractor items to complete. The measure cannot be used to differentiate between sensory neglect and motor neglect.
Feasibility	The Star Cancellation Test requires no specialized training to administer and only minimal equipment is required (a pencil and the test paper). The test is simple to score and interpret (counting the number of small stars cancelled by patient out of a total of 54). A suggested cutoff score for the presence of USN is provided (< 44 indicates the presence of USN). The test is placed at the patient’s midline and the 2 small stars in the middle are used for demonstration.
How to obtain the tool?	Please click here to see a copy of the Star Cancellation Test.

Psychometric Properties

Overview

A review of the Star Cancellation Test reported that the measure has excellent construct and criterion validityExamines the extent to which a measure provides results that are consistent with a gold standard . It is typically divided into concurrent validity and predictive validity .
, however, little published data exist on the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of this measure (Menon & Korner-Bitensky, 2004). In general, cancellation tests with distractors (e.g. the big stars in the Star Cancellation Test) are thought to be more sensitive measures of USN than cancellation tests without distractors (e.g. Albert’s Test), and are believed to have greater test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
than line bisection tests (Marsh & Kersel, 1993; Azouvi et al., 2002).

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Star Cancellation Test.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest:
Bailey, Riddoch, and Crome (2004) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Star Cancellation Test in elderly patients post-stroke (85 with neglect, 83 without neglect). For patients with neglect, the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was excellent (Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient = 0.89).

Intra-rater:
No evidence.

Inter-rater:
No evidence.

Validity

Criterion :
Marsh and Kersel (1993) examined the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of four different measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The Star Cancellation Test was found to be the most sensitive measure of visual neglect (100%) when compared with the other tests.

Bailey, Riddoch, and Crome (2000) compared cancellation measures of USN (Star Cancellation Test, Line Bisection Test, Baking Tray Task, Exploratory Motor Task, Copying a Daisy and Clock Drawing Task) that were administered to 107 patients with right or left sided brain damage and 43 age-matched controls. In this study, the Star Cancellation Test and Line Bisection Test had the highest relative sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
for visuo-spatial neglect (76.4%) when compared to the other cancellation tests.

Halligan, Wilson, and Cockburn (1990) examined the internal structure of the measures that comprise the Behavioural Inattention Test (BIT). Out of the 15 tests that comprise the BIT, the Letter Cancellation Test and Star Cancellation Test were the most sensitive measures, identifying 74% of patients with neglect.

Predictive :
Marsh and Kersel (1993) examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of four different measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. In this study, the Star Cancellation Test was found to be the best predictor of functional outcome (r = 0.55) as measured by the modified Barthel Index of Self-Care (Mahoney & Barthel, 1965).

Construct:
Convergent:
Agrell, Dehlin, and Dahlgren (1997) compared five tests of visuo-spatial neglect (Star Cancellation Test, Line Crossing Test, Line Bisection Test, Clock Drawing Test, and Copy A Cross Test) and the Barthel Index in 57 elderly patients using Spearman’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. In this study, the Star Cancellation Test correlated adequately with the Barthel Index (r = 0.48), the Line Bisection Test (r = -0.33), the Clock Drawing Test (r = -0.47) and the Copy A Cross Test (r = -0.47). The test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Line Crossing Test score (r = 0.63).
Note: Some correlations are negative because a high score on the Star Cancellation Test indicates normal performance, whereas a high score on some other measures of visual neglect indicates the presence of USN.

Marsh and Kersel (1993) examined correlations between four measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent correlations were found between the Star Cancellation Test and the Line Crossing Test (r = 0.68) and with the Indented Paragraph test (r = -0.60). An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found with the Line Bisection Test (r = -0.40).
Note: Some correlations are negative because a high score on the Star Cancellation Test indicates normal performance, whereas a high score on some other measures of visual neglect indicates the presence of USN.

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
Jehkonen et al. (1998) examined the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the Star Cancellation Test in 52 patients with a first-ever single acute right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. In this study, using the specific cutoff score for detecting the presence of USN, the Star Cancellation test had a diagnostic sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 80% and a diagnostic specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 91%. Out of all of the USN measures examined in this study (Star Cancellation; Figure Copying; Letter Cancellation; Representational drawing; Line Crossing; Line Bisection), the Star Cancellation Test was the best single test for diagnosing USN, and misdiagnosed only 4 patients with neglect and 3 patients who did not have neglect.

Responsiveness

No evidence.

References

• Agrell, B. M., Dehlin, O. I., Dahlgren, C. J. (1997). Neglect in elderly stroke patients: a comparison of five tests. Psychiatry Clin Neurosci, 51(5), 295-300.
• Azouvi, P., Samuel, C., Louis-Dreyfus, A., et al. (2002). Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. J Neurol Neurosurg Psychiatry, 73, 160 -166.
• Bailey, M. J., Riddoch, M. J., Crome, P. (2000). Evaluation of a test battery for hemineglect in elderly stroke patients for use by therapists in clinical practice. NeuroRehabilitation, 14, 139-150.
• Bailey, M. J., Riddoch, M. J., Crome, P. (2004). Test-retest stability of three tests for unilateral visual neglect in patients with stroke: Star Cancellation, Line Bisection, and the Baking Tray Task. Neuropsychological Rehabilitation, 14(4), 403-419.
• Halligan, P., Wilson, B., Cockburn, J. (1990). A short screening test for visual neglect in stroke patients. Int Disabil Stud, 12(3), 95-99.
• Jehkonen, M., Ahonen, J. P., Dastidar, P., Koivisto, A. M., Laippala, P., Vilkki, J. (1998). How to detect visual neglect in acute stroke. The Lancet, 351, 727.
• Ladavas, E. (1994). The role of visual attention in neglect: A dissociation between perceptual and directional motor neglect. Neuropsychological Rehabilitation, 4, 155-159.
• Linden, T., Samuellson, H., Skoog, I., Blomstrand, C. (2005). Visual neglect and cognitive impairment in elderly patients late after stroke. Acta Neurol Scand, 111, 163-168.
• Mahoney, F. I., Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Md State Med J, 14, 61-5.
• Mark, V. W., Woods, A. J., Ball, K. K., Roth, D. L., Mennemeier, M. (2004). Disorganized search on cancellation is not a consequence of neglect. Neurology, 63, 78-84.
• Marsh, N. V., Kersel, D. A. (1993). Screening tests for visual neglect following stroke. Neuropsychological Rehabilitation, 3, 245-257.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Small, M., Cowey, A., Ellis, S. (1994). How lateralized is visuospatial neglect? Neuropsychologia, 32(4), 449-464.
• Wilson, B., Cockburn, J., Halligan, P. (1987). Development of a behavioral test of visuospatial neglect. Arch Phys Med Rehabil, 68, 98-101.

See the measure

How to obtain the Star Cancellation Test?

Please click here to see a copy of the measure.